Provider Demographics
NPI:1992866057
Name:LONG, JACQLYN E (OD)
Entity Type:Individual
Prefix:
First Name:JACQLYN
Middle Name:E
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JACQLYN
Other - Middle Name:E
Other - Last Name:REINERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8885 LADUE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2088
Mailing Address - Country:US
Mailing Address - Phone:314-721-2720
Mailing Address - Fax:314-725-2685
Practice Address - Street 1:211 E BROADWAY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6220
Practice Address - Country:US
Practice Address - Phone:618-462-9818
Practice Address - Fax:314-741-4947
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02865152W00000X
IL046-008207152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0854830001OtherDMERC
MO318096041Medicaid
MO991722009Medicare PIN
U08986Medicare UPIN
MO1595006Medicare PIN
ILF400128269Medicare PIN